Form updated 5/12/22

Please fill in all information completely and press the submit button when you are finished. Thank you.

If you have any questions, please contact Sara Companion HomeCare Services and speak with a member of our Human Resources Team.

Mandatory Form

Tuberculosis Screening is an important way to make sure that our SARA caregivers are well. Since health can change over the course of a year, we ask that all our caregivers complete a new questionnaire annually.

Please fill in the Tuberculosis Screening form.

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Name *

First

Last

Date *

Please answer the questions accurately. Do you have any of the following? *

• Yes
• No

1. Chest pain? *

• Yes
• No

2. Productive cough for more than 3 weeks? *

• Yes
• No

3. Unintended Weight Loss? *

• Yes
• No

4. Blood-Streaked Sputum? *

• Yes
• No

5. Persistent cough for more than 3 weeks? *

• Yes
• No

6. Fever? *

• Yes
• No

7. Persistent shortness of breath? *

• Yes
• No

8. Coughing up blood? *

• Yes
• No

9. Negative TB test that converted to positive? *

• Yes
• No

10. Chills for no known reason? *

• Yes
• No

11. Unexplained fatigue for more than 3 weeks? *

• Yes
• No

12. Night sweats for no known reason? *

• Yes
• No

13. Were you born or have you lived permanently or temporarily (for > 1 month) in a country with a high TB rate (i.e. any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)? *

• Yes
• No

14. Do you have current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone>15 mg/day for >1 month) or other immunosuppressive medication? *

• Yes
• No

15. Have you had close contact with someone who's had TB? *

• Yes
• No

16. Have you ever had a positive skin test, a positive QuantiFERON or have been treated with medication for TB? *

• Yes
• No

If you answered yes to any of the questions above, please explain.

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